Are You Prepared to Discuss PrEP with Those at Risk for HIV?

Are you prepared for PrEP? Pre-exposure prophylaxis (PrEP) is the latest addition to the HIV-prevention toolbox, an FDA-approved protocol whereby people who do not have HIV can take a pill to minimize the risk of acquiring it. (In the United States, Truvada—a combination of the drugs emtricitabine and tenofovir—has been approved for this purpose.)

What is exciting about PrEP is that it allows people most at risk for HIV to engage in sexual activity with less worry and dependency on the health and/or prevention practices of partners. For people with multiple partners, or for people in serodiscordant (HIV-positive/HIV-negative) relationships, this could be a real game-changer.

This new tool also has great potential to change the narrative of HIV prevention. In the past, it was incumbent on the person who knows he or she has HIV to disclose his/her status and to take responsible action. With PrEP, prevention can be more clearly articulated as a shared responsibility. This alone can help to address stigma, as it may decrease fear of engaging in sex with someone with HIV. Plus, shared responsibility can go a long way in helping to move away from the victim/blame narrative that persists.

As with almost all prevention work, however, effective prevention is about more than taking a pill, and those of us in the mental health professions can play a vital role in filling the gaps. Here are some things therapists and counselors should know:

PrEP is not like the morning-after pill or something that can be taken only when one knows he or she is going to engage in sex. Its effectiveness relies on adherence to regular dosing. As one study outlined, different cities are showing different uptake and adherence rates, and some of this variance seems to be influenced by education levels about the importance of regular dosing.

It is important to be tested for HIV and not make assumptions about one’s status. Any good doctor, before prescribing PrEP, should take care of this, but in our clinical practices, we should encourage testing while emphasizing that this resource exists for people who are HIV-negative.

PrEP is NOT a vaccine, nor is it a guarantee of prevention. It is a risk reducer, and should be viewed as such. Other prevention tools (such as condoms or boundary-setting) should not be eschewed in favor of PrEP alone.

Increasingly, health plans and government programs are covering the costs of Truvada.

PrEP can be an empowering resource for people who are properly informed about what it is and what it isn’t, giving them a greater sense of control over their health. Mental health professionals can play an important role in helping people who are at risk for HIV to negotiate gaining access to PrEP, and to support them in using it effectively. At the same time, conversations and education regarding PrEP can help to destigmatize HIV and to increase comfort levels in talking about sex and sexual health.

Conversely, not knowing enough and/or ignoring this new option can do harm to the people we serve. I encourage people in the mental health professions to take a few minutes to research and learn some of the basics and to consider talking with at-risk people about PrEP.

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

Linda

August 4th, 2015 at
5:55 PM

Ok can I get more information on how you are treated. Is this an oral medication that you take or is it administered in another fashion. Can we get an analysis of how effective we believe the medication to be under different usage scenarios.

I ask this as I have several a friends that are at risk and giving them good information could potentially save a large amount of heartache later.

Brad Ogilvie

August 6th, 2015 at
5:42 AM

Starting with the easy question, Truvada is a pill that is prescribed to be taken daily. As for the more complex question about effectiveness, there are many variables, which is why I say that this is another tool but not, in and of itself, a cure. So, for example, if the person using Truvada takes it daily, as prescribed, and has sex with people who have HIV and are also on treatment and have a suppressed viral load, than risk of contracting HIV is almost non-existent. However, if the person only takes Truvada once a week, and has sex with someone who has recently contracted HIV and has a very active and infectious virus, then Truvada may make no difference in terms of risk. This is where things can get dicey and where education is needed. The goal is to keep a minimal level of Truvada flowing in the system, and the research seems to show that 4 dosages per week keeps it at 96% effectiveness, but we also have to be careful not to give false senses of security. We don’t want clients out there contracting HIV and saying “I was told that I only needed to take the pill 4 times a week.” This greatly reduces risk, but does not eliminate it.
In an ideal world, we can see this as a way to promote critical thinking about self and self-care, and helping clients feel a greater sense of empowerment and control, but not simply buy into the notion that a pill is the solution to my worries.
I would be glad to do what I can to answer any more questions you might have.

lauren

August 9th, 2015 at
10:01 AM

I suppose that if you know that this is the lifestyle that you lead and do not have any plans to change your ways then fine, it can be seen as a good thing. But is it overall the responsible thing to be promoting? I’m not sure. In so many ways to me it feels like this is an acceptance of a promiscuous lifestyle and that to me seems to be a very dangerous thing for us to continue to promote.

Brad Ogilvie

August 10th, 2015 at
5:31 AM

Tara – yes this is highly recommended for people who do not have HIV but are in a relationship with someone that is.
Lauren – You might want to check your ethics training about judging clients and knowing facts. Many people who are at high risk for HIV have already experienced a cultural trauma of shame and damnation, if not outright physical and sexual abuse. Our role as therapists is to empower and help with healing, not perpetuating the trauma by shaming a lifestyle.

Keith M

August 10th, 2015 at
8:58 AM

Tara – Yes, and we are getting a lot of requests from serodiscordant couples.
Lauren – Just Say No and abstinence-only sex-ed have terrible outcomes. People have the same idea about needle-exchange programs, but the research data show exactly the opposite outcomes. Stopping the spread of infectious disease should be a priority, not morally judging behavior. No-one is promoting sex, it just comes naturally. And your assumption that people who want to be protected are naturally “promiscuous” is also judgmental and not based in fact.

lauren

August 10th, 2015 at
11:28 AM

I’m sorry I guess that I was of the understanding that we were all trying to learn from each other on this site and that we should feel safe to express our own opinions. I think that there were several times in my statement that I put “I think” or “I’m not sure” but I guess that the moral of story is that if I don’t agree with the status quo on here then I am the one who is wrong.

Brad Ogilvie

August 10th, 2015 at
6:34 PM

Lauren – I certainly didn’t mean to create an unsafe space with my comment. Safe spaces, ideally, in our profession, means it is safe to disagree as well as agree. At the same time, we also do have ethical guidelines for how we deal with moral dilemmas such as ones that come up often with HIV (such as needle-exchange programs, etc.). We all have our own thoughts and opinions about a wide range of these issues, and I think it is important that we be open to exploring them. For me, I guess it was the suggestion that talking about PrEP is like condoning promiscuity does raise what might be an opinion to a level of greater concern about violating our ethical codes. Hopefully, in this space (and feel free to reach out directly as well) can be a place where these things can be talked about and explored.

Keith M

August 11th, 2015 at
6:23 AM

Lauren – I agree with Brad, and my comment was not meant to discourage conversation either; that said having been close to the virus personally since the 80’s, and professionally for the past 9 years, I tend to get a little defensive when it comes to what I see/hear as judgments of people’s insight, motivation or abilities. Asserting that people “do not have any plans to change” is assuming you can see into the hearts and minds of an entire cohort of people interested in protecting themselves and by extension stopping the spread of HIV. Far too often statements such as those come from a place of judgment, not intellectual curiosity. We are all here to learn from, and share our thoughts with one another..

Keith M

gordon

August 12th, 2015 at
10:47 AM

Once again it sounds like there is finally a way to halt the spread of this disease and to provide a real positive to those for whom this could be a real and valid concern, but all I can do is wonder how many medical insurance providers are actually going to accept and cover this? And if not how feasible is it in terms of affordability?

Keith M

August 13th, 2015 at
6:34 AM

Thankfully almost all insurance companies are covering Truvada – there have been some pre-auth issues but they are getting fewer and further between. Most state Medicaid plans cover it. Cost without insurance is around $1500/month.
And yes, insurance driving medical decisions is abhorrent. Especially those death panels :-p

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